February 22 to 25, 2018

Section A - Delegate Information
If you experience any technical difficulties when using this form or if you have registration questions, please contact General Surgery Review Program at: info@generalsurgeryreview.ca

Email Address:
Title:
First Name:
Last Name:
Program Director:
Department:
Institution:
Address Line 1:
Address Line 2:
City/Town/Village:
State/Province: (Canada or U.S.A only)

- If "Other" then please specify -

Zip/Postal Code:
Country:
Business Number: Ext:
Home/Cell Number:
Fax Number:
   
Please indicate if you have any dietary restrictions, requirements or allergies:
If special meals are required at an extra cost, charges will be applicable.
   
Special Needs:
   
Additional Comments:

I have completed or will be completing my training in 2018: Yes  No


Section B – Delegate Registration
Registration Fee includes admission to all sessions, access to audio recording archive for all sessions, and all breakfasts and lunches indicated in the program.

  Early Bird Pricing
On or before Dec. 15, 2017
Regular Price
Dec. 16, 2017 and later


$1,100.00 $1,200.00


$1,500.00 $1,600.00

Hotel Accommodation and Travel Arrangements
Participants are responsible for their own travel and accommodation arrangements. A group room rate of $142 CAD per room (single/double occupancy) per night (plus applicable taxes) is being offered to participants. Rooms at the conference rate are available until the reserved block of rooms is filled or January 25, 2018, whichever occurs first. It is therefore recommended that participants requiring accommodations book as soon as possible. You must indicate that you are with the General Surgery Review Program to receive the group rate.

Please contact the hotel directly and quote the group code 'BB19AA’ at:

Sheraton Toronto Airport Hotel and Conference Centre
801 Dixon Road
Toronto, Ontario
M9W 1J5
Tel: (416) 675-6100

Or book online at: Sheraton Toronto Airport Hotel and Conference Centre

 


Section C – Payment Information
Please verify all the information is correct. By submitting your payment your credit card statement will show this transaction as General Surgery Review Program.

Cancellation Policy
All cancellations must be received in writing no later than February 9, 2018 for a full refund, less an administrative fee of $100.00. No refunds will be issued after this date.

I acknowledge that I have read and accept the conditions of this policy.

 


Section D - Participant Consent & Release Agreement
(Please scroll to the end and click on I AGREE after reading.)

CONSENT TO BE VIDEO RECORDED, AUDIO RECORDED, PHOTOGRAPHED, RECORDED AND/OR TO HAVE PUBLIC DISCLOSURE OF INFORMATION, AND WAIVER OF CONFIDENTIALITY FOR MEDIA PURPOSES.

I hereby give my permission and express written consent to General Surgery Review (GSR) to digitally video record, videotape, digitally audio record and/or photograph me while I am attending and participating in the GSR. I further consent to GSR and its agents and assigns exhibiting, showing, re-producing, publishing, displaying, transmitting and other uses of all such video and audio recordings and photographic images in any media whatsoever in Canada or elsewhere, including presentations made for medical, scientific, educational and related marketing purposes.

I further acknowledge, confirm and agree that I shall have no right to inspect or approve any video and audio recordings and/or photograph(s) of me prior to it or their use by GSR or its agents and assigns in any manner and confirm and agree that I will receive no financial compensation arising from such use, including, without limitation, my providing services as a model.

I hereby fully and finally release GSR and its agents and assigns from any and all liability directly or indirectly arising out of the video and audio recordings and photographic images made and/or taken of me including, without limitation, how such recordings and images are used by GSR and its agents and assigns, the final form of such recordings and photographs and the timing, method and basis of it or their publication and distribution.

I acknowledge that GSR and its agents and assigns shall have the right to cancel any event offered or organized by GSR or its agents and assigns for which I may register to attend up to and including the day immediately prior to the scheduled commencement date of such event by email notification to me at the last email address I have electronically delivered to GSR. I hereby further release GSR and its agents and assigns from any and all claims relating directly or indirectly to such cancellation that I or my heirs, executors and administrators may have and hereby confirm and agree that GSR and its agents and assigns shall at no time be liable to me or my heirs, executors and administrators for any direct or consequential losses, damages, expenses or costs which I may suffer or incur as a result of a cancellation, including, without limitation, unnecessary travel expenses and loss of income.

WAIVER OF LIABILITY AND ASSUMPTION OF RISK ACKNOWLEDGEMENT

In consideration of GSR permitting me to participate in any capacity whatsoever in the GSR (including but not limited to participation as an attendee or speaker), I hereby agree to the following terms:

  1. I expressly warrant and represent that by attending the GSR I am knowingly, freely and irrevocably assuming all risk while participating in and or attending the GSR, in any manner whatsoever, regardless of how, where or when I may incur or sustain any injury, damage or loss, and whether or not resulting from the negligence of GSR or otherwise.
  2. None of GSR or its directors, officers, employees, agents or consultants (the “Releasees”) shall be liable nor held responsible in law by me, or my heirs, executors, assigns and any legal or personal representatives for any physical bodily injury (including loss of life or limb), damage or other loss (including but not limited to economic loss) incurred by me, however sustained or incurred at any time during my participation or attendance at the GSR, including my travel time to and from the GSR.
  3. I hereby irrevocably release and hold the Releasees harmless in respect of any and all liability for and in respect of my physical injuries and/or economic loss derived from my participation and involvement, in any manner, in the GSR.
  4. Once I have agreed to this Participant Consent and Release Agreement, it will constitute a full answer and defence in favour of the Releasees in relation to any claim that I may advance against same for any physical injury, damage or loss sustained by me while participating in or attending the GSR.
  5. I understand that it is a condition of my participation in the GSR that I must agree to the terms of this Participant Consent & Release Agreement and that I am under no requirement or compulsion to participate or attend the GSR and I am free to decline participation if these terms are not acceptable to me.
  6. While attending the GSR I agree to abide by all rules posted or otherwise provided to me, as well as all applicable federal, provincial and municipal laws and regulations.
  7. I agree that regardless of actual causation, I am solely responsible for my safety while participating and attending the GSR.
  8. I understand that this is an exam preparation course and that GSR is not liable for my individual test results and/or failure of any professional exam as a result of participating in this program.
  9. I shall not disclose or share any course material, audio files or any provided passwords received by the GSR to any third party and acknowledge and agree that any breach whatsoever will result in no longer having access to all materials provided.

I have read the foregoing Participant Consent & Release Agreement and confirm and agree that I fully understand its contents. I hereby warrant that I am of legal age and am competent to contract. I hereby provide and deliver both my express and informed consent as stated above and my agreement with the terms as outlined above by clicking on the I AGREE button as presented on this website and confirm that this Participant Consent & Release Agreement when given in this manner shall be forever binding upon me.

I consent to have my name, address and email added to the mailing database for upcoming conferences: Yes    No

 


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Already Registered?

If you have already registered but have not yet paid you can pay your registration fee here.

If you experience any technical difficulties when using this form or if you have registration questions, please contact General Surgery Review Program at: info@generalsurgeryreview.ca

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